The Therapy Diaries 2 | Cognitive Behavioural Therapy with Exposure

My last post in this series looked at my time with the school counselling service to help deal with my anxiety issues and my emetophobia. This time, I’m looking at my first ever experience of cognitive behavioural therapy (CBT), which happened during the few months before I went to university.

Disclaimer: I am not a mental health professional in any way, so any recommendations are based on my own personal experiences. If you are concerned about yours or a loved one’s mental health you should seek support from the links below. I will include links to further information at the end of this post should you wish to find out more about each type of therapy, but please bear in mind that this post is based on my own experience so will more likely differ from everyone else’s. In addition, I’m looking back over the last 10+ years in some cases, so some procedures mentioned may be different to what they are now.

Cognitive Behavioural Therapy

I was referred for my first course of CBT when I was around 17. At the time, I was experiencing some very severe stomach issues that were causing me horrific nausea. As I also had emetophobia, this was not a good combination, and every time I felt the slightest bit off, my anxiety would soar, making – you guessed it – the nausea worse. It was a vicious cycle that meant I was starting to spend time off school and that eating was just a horrible task. While numerous doctors diagnosed me with IBS, there was one incidence where I needed the day off school because of how poorly I felt and I got myself into one of the worst states I’ve ever been in as a result. My Mum, who was completely and utterly sick of my shit, dragged me to yet another doctors appointment, where it became clear that rather than throwing yet another prescription my way (many of which I was too scared to take in case they made me sick), I needed some help for the emetophobia.

I was referred to the psychology service at my doctors surgery where after a few weeks, I had my consultation with a mental health worker. It was agreed that I would be allocated ten sessions of cognitive behavioural therapy. At this point, there wasn’t much of a wait – well, it was six weeks – but this was a time where six weeks actually meant six weeks, so compared to how long I was waiting for my most recent treatment, looking back, it was nothing.

What it Involves

According to Mind, cognitive behavioural therapy (CBT) is a form of talking therapy that examines how your thoughts and beliefs affect your feelings and behaviours, while teaching you coping strategies for dealing with your issues. It’s one of the most common treatments offered for certain mental health conditions, and the National Institute of Clinical Excellence (NICE) guidelines recommend it as the treatment of choice for anxiety and depression. It can be used alone or alongside medication, depending on the severity of the symptoms. In the UK, it’s currently available through the NHS through a service known as IAPT (Improving Access to Psychological Therapies), but this often has long waiting lists and for many, it can be a bit of a postcode lottery. You can also access it privately, but it’s important to seek out a therapist who is registered with the British Association for Counselling and Psychotherapists (BACP), the governing body for therapeutic practice.

CBT is usually a short-term form of therapy, and this can be anything between 4 and 12 sessions depending on the area you live and the severity of your symptoms. It uses a number of techniques, some of which can include: 

• Cognitive restructuring – Identifying and reframing certain negative thought patterns. 
• Exposure therapy – Confronting situations that promote anxiety while making use of coping strategies. 
• Behavioural experiments – Predicting what you think is going to happen before a certain event, and later looking at whether or not your prediction came true. 
• Relaxation – Teaching techniques such as mindfulness and breathing exercises as a way of managing stress and anxiety.
• Journaling – Writing down any thoughts and feelings experienced between sessions.

A key component of CBT is also homework, where the therapist assigns the client with a particular task to carry out outside of the therapy environment. The outcomes of this along with any challenges faced are then discussed again during the next session.

My Experience

Over the course of this treatment, I saw three different mental health workers. One for my initial consultation, one for my first couple of sessions (we’ll call her C), and I was then allocated a newly qualified mental health worker (we’ll call her L) who was specialising in phobias. Out of the three, I preferred L, who was the newly qualified one. She was much younger than the first two so it felt much easier to open up to her, and it seemed as though she was much more compassionate, presumably because she was fresh out of uni.

The main aims of this CBT were to tackle the emetophobia, which had clearly started to impact my day to day life. This is where I had my first taste of exposure therapy. As I was studying A-level psychology at the time (and had applied to study it at university), I had an idea of what this was. L helped me put together a hierarchy of exposure tasks, and had taught me a number of breathing techniques to help me deal with the anxiety they would inevitably cause. While doing the exposure tasks, I had to record how I felt before, during and after each situation, in the hopes that it would highlight that nothing happened, and that I would become desensitised to the situation. I can’t remember the list in full, but below I’ve listed some of the tasks I vividly remember.

Trigger Warning: Emetophobia

While I can assure you I do not share any videos/images that I was subjected to during my exposure treatment, if you suffer with emetophobia you may find a few of these bits triggering, so please proceed with caution.

• I had to wait a minimum of ten minutes before washing my hands after I got home from the doctor’s surgery where I was having my sessions.
• I was given a slab of parmesan cheese which I had to smell at regular intervals (a particular cheese famously known to smell familiar). That bit was going well until my Mum took it out of the fridge and made a sandwich with it!
• L and I both ate vegetable soup out of a cardboard vomit bowl. Honestly, this one was the worst. It looked far too real and it just felt horrifically wrong. This was also fairly low on the list too so it was surprising how much anxiety it induced! I remember she brought it in a jug (WTF?) and the way it was poured made it seem a bit too realistic. 
• I had to watch a two minute clip called “Sick Film” – the clip basically involved a woman trying to make herself sick, and included a lot of gagging and retching. I was told up front that she didn’t actually vomit, but at times I genuinely thought I was being lied to. Please do not Google this film. It’s one of those ‘artistic’ projects that’s essentially a film of people being sick. How that’s art is absolutely beyond me but you know, whatever floats your boat. Subsequently, I had to watch this film clip at least three times a day for the week in between sessions. 
• I had to listen to a sound clip of someone vomiting. Again, I had to listen to this regularly during the week between my sessions. Fun times!

The sound clip was as far as I got in terms of my exposure tasks, but I distinctly remember a discussion with L about how the end goal would be to watch her vomit. She was genuinely willing to make herself throw up. If that’s not commitment, I don’t know what is. Thankfully, it never happened, as while all of this was happening, I received my exam results and was accepted into the University of Northampton. 

While it wasn’t the most practical to be leaving slap bang in the middle of my treatment, L and C (who I’m assuming was her supervisor) assured me that they would write me a letter to take to my new doctor’s surgery in order to continue my treatment in Northampton. Great. I had my last session, and was told to phone the surgery in a week’s time to check my letter was ready before coming to collect it. 

I did as I was told, and not surprisingly, the letter wasn’t there. There was no record of me being given a letter on my notes, and the receptionist had no idea who L was – honestly, it was a shambles – but assured me she would try and speak to C to see what was going on. That was the last I heard. Admittedly, I probably could have pushed harder to get something done, but combined with packing and practising for my driving test (spoiler alert: I failed it) in preparation for my leaving home in September, I just decided to draw a line under it.

The Good

• There was plenty of structure with some clear goals set. 
• The overall wait for an appointment wasn’t very long, and in most cases I managed to get weekly appointments. 
• Having a younger and more recently qualified therapist felt as though she was more up to speed with things. She certainly was more committed – I’m not sure I’d willingly make myself sick for a patient!

The Bad

• Unorganised AF. Given that I had my appointments in the doctors surgery, there were multiple occasions where they didn’t have a free room and my appointment was postponed. I was once asked if I’d be willing to have my session in a café – um, no. Plus, there’s the whole letter saga. 
• At the beginning of every session, I was given the Beck Depression Inventory. Great that they were keeping tabs on my mood, but given that I was there for a phobia rather than any form of depression, it seemed a bit pointless and generic.
• While the emetophobia exposure was beneficial to an extent, particularly with the videos and sound clips it felt as though I was getting desensitised to the specific thing. It’s the same as certain TV shows and movies – to this day I can watch pretty much all of the offending episodes of The Inbetweeners with no problem, because I’ve seen them so many times, but you can guarantee if anyone throws up in front of me I will lose my shit. My point being that there could have perhaps been a few more real life situations thrown in. 

Final Thoughts

Overall, despite the fact that things didn’t go too well towards the end, most of my CBT experience was a positive one. I felt for a while that progress was being made, and I got on really well with both L and C. I’m not entirely sure who’s fault it was, but I feel there definitely could have been more organisation on their end too, particularly when it came to the allocation of rooms and the whole letter thing. I feel that the exposure tasks were helpful at the time, but I think because they weren’t really continued, there wasn’t really time for it to stick.

Additional Support and Information

The following contact details are based within the UK. If you live outside of the UK and need mental health support, CALM has a list of international organisations that you can get in touch with. 

Mind

Mental health support and information. Use this page if you are in need of urgent help.

Samaritans

Free, confidential mental health support available 24 hours a day, 365 days a year. Call from the UK for free on 116 123. 

Childline

Free, confidential support from trained counsellors for anyone under the age of 19. Call from the UK for free on 0800 1111.

CALM (Campaign Against Living Miserably)

Free and confidential crisis support available 7 days a week, from 5pm till midnight. Call from the UK on 0800 58 58 58 or use the free webchat.

References

9 CBT Techniques for Better Mental Health – Healthline

About Cognitive Behavioural Therapy – Mind

Have you ever had CBT or exposure therapy? Let’s chat! Leave your experiences in the comments below.